INTRODUCTION

Some changes in the epidemiological transition of the last decade have been characterized by increases in the life expectancy of the populations, and therefore, by increases in chronic degenerative illnesses as well. In order to address this new reality, healthcare professionals are required to adjust their perspective of care and provide the necessary attention to chronic patients, including Palliative Care (PC).

Palliative Care, as a special care approach, is mainly focused on improving the quality of life of chronic patients through addressing the symptoms and secondary effects of the treatments. Palliative Care has a goal of helping patients suffering from a serious illness to live as best as possible and for as lodieng as possible; in other words, to live with quality, or as Cicely Saunders expresses "... to live until the day you die" ¹. The WHO estimates that annually 40 million persons - of which 78% live in low or middle income countries - are in need of palliative care ².

Around 75% of all people will die due to one or several chronic progressive illnesses, meaning that simultaneously, they will require a great deal of attention, will face important ethical and clinical decisions, and will use diverse healthcare and social services ³; therefore, the timely identification of patients requiring palliative care can increase the likelihood of improving their quality of life, while at the same time, respecting their values and beliefs through the best care practices ^2,4.

MATERIALS AND METHODS

This is a quantitative, descriptive, transversal, and correlational study on a population of 50 patients with complex chronic degenerative illnesses, hospitalized in an institution of 3rd level of care in the City of Mexico [N=157]. The unit of analysis was the hospitalized patient (in floors 1,2, or 3), of both sexes, who were in the hospital because of illness (1 to 3 months).

A pilot was carried out with 11 patients having similar characteristics. The NECPAL CCOMS-ICO© 3.1 ⁹ instrument adapted by Ayala, Carmona and Ponce 2019 was used.

The criteria of inclusion were:

The sample was by convenience due to the current sanitary emergency because of COVID-19. The variables of interest considered were:

The Kuder-Richardson Reliability Test turned out to be 0.73 suggesting a good internal consistency. The clinical history, medical appliances checklist, and patients and their families interviews were used. Patients were assessed from the 7th day of their registration during a 2-3 days period. Descriptive statistics; instrument scores weights; and inferential statistics were all calculated.

Table No. 1. 

Source: authors.

Data were processed using SPSS version 25. The study was approved by the ethics committee of the hospital. An informed consent was obtained from all the participants regarding their assessments and data gathering. The study followed the guidelines of the General Law of Health article 4th as well as those of the Deontological Code of Nursing.

RESULTS

The average age of the participants was 58 years old. Fifty eight percent were female. The average hospital stay was 44 days. Most participants had their residencies in other states; and 56.6% were married. The average of existing comorbidities in the participants was 3. Chronic pulmonary illnesses accounted for 30% of the total. Cardiac illness accounted for 27% of the total. The average weight loss was 3.38 kilograms (Graph 1).

Graph 1. Nutrition decline / Weight loss. 

44% of the participants were postrated on bed 24 hours a day with a serious health status; nevertheless, 84% of these hospitalized patients required some degree of nursing medical attention, including total support (Graph 2).

Graph 2. Functional decline / Karnofsky Scale. 

Cognitive decline in terms of orientation, memory, and language was detected in 54% of these patients in a moderate to severe level, making it necessary to have nursing interventions.

Fragility was found in 82% of these patients regarding infections (41%), delirium (64%), and dysphagia (62%) (Graph 3).

Graph 3. Fragility Signs / geriatric syndrome. 

Regarding persistent symptoms, 84% of these patients manifest chronic pain, 74% had no appetite, 70% showed respiratory distress, 64% were in a state of somnolence most of the day (Graph 4).

Graph 4. Physical distress symptoms. 

All patients (100%) showed progressive illnesses with 8 or more persistent symptoms.

The NECPAL dimensions are shown in Graph 5. Nine out of ten participants manifested psychological distress, and 7 out of 10 presented social vulnerability. All these indicators highlight the magnitude of the pain, risk, and vulnerability which these patients undergo.

Graph 5. Percentage of population which is affected / NECPAL Dimension. 

The needs regarding palliative care were from high to very high in 95% of the population (Graph 6).

Graph 6. % with needs of Palliative Care. 

Inferential statistics were calculated with a confidence interval of 95%. The Spearman's R for non parametric samples (n = 50) yielded the following significant values:

Regarding the dimensions of fragility and age, a weak and positive association was found (R Spearman = .471, p=.001), suggesting that the older the patients are, the more symptoms of fragility they suffer.

Regarding the dimensions nutritional decline and physical distress, a weak and positive association was found, reflecting what happens in 40% of cases of the study, and suggesting that the more nutritional decline the patients have, the more physical distress they suffer (R Spearman = .424, p= .002).

A weak and positive association was found between fragility and nutritional decline which reflects what happens in 33% of the cases in this study, suggesting that the more fragility the patients show, the more nutritional decline they have (R Spearman .336 , p=.017).

A mid size and positive association was found between fragility and the palliative care need (R Spearman .424 y p= .002), suggesting that, the more fragility the patients show, the more palliative care needs they have. This was clear in 42% of the cases of the study.

A mid size and positive association was found between cognitive decline and palliative care (R Spearman .550, p=.000), suggesting that the more cognitive decline the patients have, the more palliative care they need.

An association was also found between palliative care needs and nutritional decline (R Spearman .550, prob= .000), suggesting that the more nutritional decline the patients have, the more palliative care they need.

Regarding differences in sex and palliative care needs, Mann-Whitney U test was calculated. There were no significant differences between women and men ( p≥.05).

DISCUSSION

The nutritional decline of these patients reveals that 7 out of 10 participants have some degree of weight loss. A similar finding was reported in Colombia ¹⁰. Moreover, in women between 60 and 74 years old, a weight loss of more than 5% has been associated with a double risk of disability in comparison with those without weight loss¹¹.

Regarding the functional decline measured with the Karnoksky scale ¹², and considering the retrospective study by Zamora et al., in Spain ¹³, it is believed that pain and other oncologic signs are related with the functional decline; nevertheless, in this study such association was not found.

Camargo and Laguado in Colombia ¹⁴ refer that 41.7% of the participants in their study showed some cognitive decline in the dimensions of orientation, balance, memory, and language. In this study, 54% of patients demonstrated such association.

Escuin et al¹⁵., detected in more than 50% of the participants in their study some nutritional, functional, and cognitive decline, as well as severe dependency in more than 90% of the cases which also presented geriatric syndromes and persistent symptoms. This finding is similar to what was found in the present study.

Regarding the presence of a component of fragility in terms of Wagner's Model ¹⁶, in relation to a syndrome of biological reduction and accumulation of stress and multiple physiological problems in older adults with complex chronic problems, a study carried out in Latin America showed that fragility was clearly associated with the number of comorbidities and the degree of cognitive decline ¹⁷.

CONCLUSIONS

The present study contributes to acknowledging the needs of palliative care which older adults with complex chronic conditions require. Moreover, the palliative care can reduce the burden of economic and social costs to the families.

The promotion of planning of palliative care avoids unnecessary treatments, a situation which can reduce further body intervention complications. The healthcare teams should share the objectives of palliative care in order to provide comfort to the patient and also reduce the stress on a single healthcare provider.

This study also promotes a reflection on the design of better palliative care protocols based on the early identification of needs and the use of modern and validated instruments in order to address the diverse and complex needs of these populations.

Palliative care should be extended to patients with chronic illnesses who are not necessarily in advanced stages. People requiring palliative care are not only persons with cancer, but also those suffering from complex chronic illnesses of the heart, lungs, kidneys, or because of complications from HIV. Palliative care should always consider the relief of pain and suffering and the security all basic needs.

A fundamental function of healthcare teams is to contribute to the improvement and support of patients in their final stage of life. These healthcare teams should constantly be trained and updated, just as Murray and Sheikh suggest. The Model of Palliative Care of Wagner for chronic patients is a successful reference guide. Therefore, the health system in Mexico should evolve in its health politics and personnel formation regarding the provision of palliative care.